"His big thing is economic development. Well, buddy, we can't do anything in about six counties in the state because they don't have a hospital."

(Julie Bennett / jbennett@al.com)

MONTGOMERY, Alabama –Three months before the implementation of key provisions of the Affordable Care Act – expanded Medicaid programs and coverage on insurance exchanges - Gov. Robert Bentley maintains Alabama is doing the right thing by participating in neither.

“I have a long-term goal for this. My long term goal is to resist the implementation of the Affordable Care Act and I believe we are going to succeed in that,” Bentley said.

“If you don’t expand Medicaid - I don’t care what anyone says - you probably cannot implement the Affordable Care Act. If you don’t have a state-based exchange, it’s going to be difficult to implement the Affordable Care Act,” Bentley said.

It seems every few weeks someone is asking Alabama's doctor governor if he, like some other GOP governors, has changed his mind regarding a Medicaid expansion.

Advocates for the poor say it would bring health care coverage to 300,000 Alabamians. Retirement Systems of Alabama CEO David Bronner has said it is idiotic to turn down the federal money that would come with expansion.

Bentley, in an interview last week, is unapologetic saying he believes he is acting in the best interest of Alabama and the rest of the country.

“May I say there is nothing free in America. The money that comes into this state is not free money. It’s money that the Chinese have loaned the United States because we are $17 trillion dollars in debt,” Bentley said.

Bentley, a dermatologist by profession, said he would not expand a “broken “ Medicaid system. However, he said the state is doing the right thing by moving to create a network of regionally managed care organizations that will supervise Medicaid patients and the delivery of their medical care.

"The system was poorly designed and it truly was broken. Our concentration has to be how we are going to fix the system forward," Bentley said.

So does that mean Medicaid will become unbroken enough to merit an expansion?

“I get asked this. Is there a time where you would ever consider expanding Medicaid? As of right now, no,” Bentley said.

Bentley’s words have become something of a political Rorschach test for listeners. Opponents of expansion, praise his opposition. While advocates of expansion cling to a glimmer of hope in words like “right now.”

Political pressure on both sides

Bentley, running for re-election, is less than nine months away from the gubernatorial primary. He won his 2010 primary battle in a surprise upset. Now, unless a game changing challenger appears, Bentley looks to have a cake walk to a second term.

Expanding Medicaid could be politically toxic for Bentley because of the unpopularity of what’s become known as Obamacare with Republicans in the deeply red state.

“They see it as synonymous with Obama and they don’t like anything Obama does, foreign or domestic,” said William Stewart, the former chairman of the political science department at the University of Alabama

Bentley maintains such political calculations are not part of his decision-making.

“Honestly, I do not look at it in that way,” Bentley said.

“My stand has been the same today as it was 2009. I was against the passage of (the Affordable Care Act.) It was sickening the day that they had the one vote. If there had been one extra Republican vote in the Senate it would have never passed. And the country would be a lot better off,” Bentley said.

On the other end of the political spectrum, Democrats made calling for an expansion a major talking point during the 2013 legislative session and are expected to hammer the issue into 2014.

“If I was running as a Democrat I would point out how many people need access to medical care in the state,” Stewart said.

The Affordable Care Act expands Medicaid coverage for most low-income adults to 138% of the federal poverty level, which in 2012 was $15,415 for an individual and $26,344 for a family of three.

The federal government would pay 100 percent of those newly eligible for the first three years and then the state's share of the cost will gradually grow to 10 percent.

A University of Alabama at Birmingham study last year said that the expansion in Alabama will provide Medicaid coverage to an additional 300,000 people and generate $20 billion in economic activity which will add $1.7 billion in tax revenue.

Bronner has said the decision to expansion is "easy math" and other Republican governors have opted for expansion because, “they know they can’t afford to say no.”

“A hatred of Obama or a hatred of Obamacare is irrelevant. If they do away with it, they do away it, fine. But if they don’t, and you don’t take advantage of it, all that happens is the other people in the state of Alabama pay these hospital bills and bills for medical care for 300,000 people that we didn’t have to pay for,” Bronner said.

Bentley said he disagrees that Medicaid would be a major job creator.

Twenty-six states are moving forward toward expansion, according to the Kaiser Family Foundation, while debate is ongoing in three state.

Bentley is one of about 14 governors who have been most vocal against expansion.

"They would have already implemented much of this, had there not been governors like me and a number of governors across the country who have said we are not going to expand Medicaid and we are not going to create a state-based exchange," Bentley said.

Hospitals are also encouraging Bentley to change his mind, said Mike Horsley, CEO of the Alabama Hospital Association.

Hospitals are concerned about planned cuts to federal payments they get for the uncompensated care of poor patients. The funds, known as Disproportionate Share Hospital allotments, are scheduled to decrease as those low-income individuals presumably gain health coverage through a Medicaid expansion.

Without an expansion, Horsley said hospitals could be left on the hook for millions of dollars in uncompensated care. That, combined, with Medicare cuts, he said could be fatal blows to some rural hospitals.

Alabama is expected to lose $14 million in DSH dollars next fiscal year. The amount of future reductions hasn’t been decided yet.

There is no deadline for the states to make a decision. But Bronner points out by waiting, the state is turning down federal dollars.

“His big thing is economic development. Well, buddy, we can’t do anything in about six counties in the state because they don’t have a hospital. When we start closing the other ones, who in the world would bring their company to a county where the hospital is closing. No businessman in America with any brains would do that,” Bronner said.